Does medical aid cover therapy in Zimbabwe?

For many people, the question that decides whether they book at all isn't whether therapy would help. It is what it costs, and whether medical aid will carry any of it.

The short answer is that most societies do cover consultations with a registered psychologist, usually from a specialist or ancillary benefit rather than your general practitioner benefit. What varies — and varies enough to warrant ten minutes on the phone before you book — is how many sessions you get in a year. Medical aid societies under the Association of Health Funders of Zimbabwe (AHFoZ) normally cover consultation and do not require pre-authorisation but may request a referral from a general practitioner/medical doctor.

Why "covered" rarely means "free"

Three separate things determine what you pay, and it helps to keep them apart.

Whether the benefit exists at all. Psychology usually sits under a specialist or ancillary benefit with its own annual limit, separate from your day-to-day medical benefit. If that limit is already spent on other specialists, the cover is gone regardless of what the schedule says about psychology.

Whether the society pays the full fee. Societies under AHFoZ pay the tariffs approved by the association, and those that are not part of AHFoZ pay at their own tariff. Where a practitioner's fee is higher than that tariff, the difference — the shortfall — is yours, payable at the time of the session. This is the part that surprises people most often, because "I'm covered" and "I pay nothing" are not the same sentence.

Whether you need permission first. Some benefits require pre-authorisation, meaning the society agrees to the sessions before they happen. Sessions taken without it may be rejected afterwards, even when the benefit existed.

We currently bill First Mutual Health, PSMAS, BonVie, Maisha, FBC, Fidelity Life Medical Aid Society (FLIMAS) and Alliance Health Options, and we are working on adding more societies to that list. Whoever you are with, check with your own society directly and confirm three things: that your scheme covers mental health services, what your limits are, and whether pre-authorisation is required.

What to ask your society before your first appointment

Call the number on your card and ask these questions, in this order. Write down the answers and the reference number.

• Do I have cover for consultations with a clinical or counselling psychologist? Which benefit does it come from?
• How many sessions per year does that benefit allow, per member and per dependant?
• Do I need pre-authorisation? If so, what do you need from me or from the practitioner?
• What does the society pay per session, and will there be a shortfall?
• Is the benefit affected by anything already claimed this year?
• Does a referral letter from a GP change any of the above?

The last one matters more than people expect. Some benefits behave differently — sometimes better — when a GP has referred you.

If you are paying for it yourself

Plenty of people do, either because their benefit is exhausted or because they would rather the sessions did not go through the society at all. That is a legitimate choice, and it is worth knowing what it buys you: a self-funded session generates no claim, no diagnostic code and no record with your society.

What your society does and does not see

If you claim, the society receives what it needs to pay the claim — that you attended, when, the practitioner, and a billing code that indicates the type of consultation. A diagnostic code is included on the claim form.

What it does not receive is the content of your sessions. What you talk about in the room is not reported to your medical aid, your employer, or anyone paying the bill on your behalf. If a family member's account is funding the sessions, the same holds: paying for someone's therapy does not entitle anyone to hear about it.

The practical version

Ring your society, ask the six questions above, and then book. Most people find they have more cover than they assumed and a smaller shortfall than they feared — but the only way to know is to ask your own society about your own plan, because no two answers here are the same.

If the cover turns out to be thin, say so when you book rather than quietly not coming back. Where a society pays less than the fee, we ask the client to pay the difference — which is a much easier conversation to have before the first session than after it.